规范日间手术病历书写若干问题的思考

摘要

日间手术开展过程中面临现行住院病历书写要求与日间手术的快速周转不适应、不能体现日间手术管理的重点环节及充分的医患沟通、无法适应医保管理及缺乏特殊情形下病历的书写与处理原则等问题,制约了日间手术快速、规范的发展.结合浙江省在规范日间手术病历书写方面的实践,就规范日间手术病历书写的有关问题进行讨论分析,提出相关建议,为各医疗机构规范开展日间手术提供参考.%The process of ambulatory surgery in China is faced with such challenges as the conflict between convention medical record writing requirements and time sensitiveness of ambulatory surgery, difficulty to fully take care of key points of ambulatory surgery and sufficient doctor-patient communication, difficulty to adapt to medical insurance requirements and absence of medical record writing norms for special circumstances. In this consideration, the practices of Zhejiang province were cited for a discussion on related issues, for reference of medical institutions in their standardization of ambulatory surgery.